1. Laparoscopic hysterectomy (case report)
Dr Salama hamid Abbas
FICOG_CABOG_DOG_DMAS
AL_KARKH BIRTH HOSPITAL_BAGHDAD_September 2012

2. Definition
Laparoscopic hysterectomy LH is a minimal access surgical procedure which facilitate the removal of non prolapsed uterus through vaginal route with the use of laparoscope

3. Classification of LH Garry &Reich classification
Type 1 -diagnostic laparoscopic +vaginal hysterectomy
Type2 -laparoscopic vault suspension after vaginal hysterectomy
Type3 –LAVH (laparoscopic assisted vaginal hysterectomy)
Type4 _ LH (laparoscopic ligation of uterine a.)
Type5 _TLH
Type6 –LSH (supracervical hysterectomy)
Type7 –LHL (hysterectomy+lymphadenectomy)
Type8_LHL+O (as above+omentectomy)
Type9 _RLH (radical laparoscopic hysterectomy)

4. LAVH Definition Is the procedure using laparoscopic surgical technique & instruments to remove non prolapsed uterus with or without ovaries through the vagina

5. Indications of LAVH Are traditionally contraindications of non descent vaginal hysterectomy
Previous pelvic surgery
Endometiosis
Previous cesarean section
Pelvic peritonitis
Suspected adnexal pathology
Uterine myoma
Ectopic pregnancy
Acute or chronic PID
Minimal uterine mobility &limited vaginal access

6. Contraindications 1.Severe COPD or cardiac disease
2.Generalized peritonitis
3.Previous extensive abdominal surgery
4.Hyper or hypocoaguable state
5.Uterus more than 24 weeks size
6.Huge cervical or broad ligament myoma

7. Hardware required Telescope 10mm 30 degree Uterine manipulator
Grasper 5mm (2)
Scissor 5mm
Dissector 5mm
Bipolar & monopolar electrocautery
Needle holder
for suction irrigation Succer

8. Procedure Preoperative measures Patient position Catheterization
Bowel preparation
Anaesthetic&medical check up
Patient position
Steep trendelenberg & lithotomy position

9. Position of the surgical team
Surgeon (1 or 2),assistant &camera man. Surgeon &camera man on the left side of the patient,the assistant is on the other side.
During vaginal part of operation the surgeon & assistant are moved to work vaginally ,moniter is between patient legs

10. Port Position -Umblical 10 mm port for telescope
-Two 5mm ports on each side of the telescope 5 cm distence for grasper,succer & electro-coagulation(working ports)

11. Surgerical Steps _Creation of pneumoperitoneum
_Diagnostic lap aroscopy to see pelvic sidewall ,anterior & posterior culdesac
_Elevation of uterus by the help of
uterine manipulator
Laparoscopic dissection _
_Vaginal procedure

12. Pneumoperitoneum

13. Port position

14. operative procedure Laparoscopic part
Elevation of the uterus coagulation &cutting of round lig.& adnexa Dissection of bladder &broad lig. up to uterine artery bilaterally

15. Laparoscopic dissection

16. Vaginal procedure Retractor is placed into the bladder peritoneum
anterior Bladder is seperated from uterus, peritoneum is opened
Retractor is placed into the bladder peritoneum
Successive dissection around the cervix is performed until the proximal point that was performed laparoscopically is reached
Successive clamping of transverse cervical ligaments & uterine arteries from below Closure of vault horizontally in one layer
The pedicles were inspected laparoscopically from above

17. Removal of uterus totally

18. Closure of vagina from below

19. In LAVH 1% 1-2% In abdominal hysterectomy TLH 3-4%
Ureteric Injury
In LAVH 1%
1-2% In abdominal hysterectomy
TLH 3-4%

20. Scarless hysterectomy

21. Operation and postoperative period passed smoothly

22. Team Work Dr Salama Hamid Abbas Dr rabeah hamid abbas dr alaa hatem a
Team Work Dr Salama Hamid Abbas Dr rabeah hamid abbas dr alaa hatem a.alkarim dr ammar hamid hannosh

23. Be not afraid of growing slowly Be afraid of standing still
Thank you